DOACs a reasonable alternative to warfarin in patients with CVST

An international real-world study backs up the use of direct oral anticoagulants (DOACs) as an effective and safer alternative to warfarin in treating cerebral venous thrombosis (CVST).

The retrospective ACTION-CVT study analysed data on 845 CVT patients (65% female, mean age 45 years) from 27 centres across the US, Europe and New Zealand, of which 33% received DOACs, 52% received warfarin, and 15% received both treatments at different times.

The results, published in the journal Stroke, showed that at a median follow-up of 345 days there were 5.7 recurrent venous thrombosis events, 3.8 major haemorrhages, and 1.8 deaths per 100 patient-years.

Compared with warfarin, DOAC treatment was linked with a similar risk of recurrent venous thrombosis (aHR, 0.94), death (aHR, 0.78), and rate of partial/complete recanalization (aOR, 0.92).

But crucially, DOACs were linked with a significantly lower risk of major haemorrhage (aHR, 0.35), occurring in  2.44 per 100 patient-years on DOAC versus 4.70 per 100 patient years on warfarin.

Intracranial haemorrhage also occurred significantly less frequently in patients taking DOAC compared to warfarin (1.52 versus 3.51 per 100 patient years, respectively), but while the frequency of extracranial haemorrhage was numerically less with DOAC the difference was not statistically significant to that seen with warfarin (0.91 and 1.15 per 100 patient-years, respectively).

According to the authors, the findings were “consistent with other studies showing similar efficacy but improved safety with DOACs compared with warfarin”, and “support current evidence that DOACs represent a reasonable alternative to warfarin in patients  with CVT.”

However, they also noted that while blood level monitoring is not necessary with DOAC’s, on the whole these medicines are more expensive than warfarin. “Thus, further studies are needed to test whether the  improved safety profile of DOACs is cost-effective”.

Also, they stressed that the study’s results should be “interpreted with caution” given its potential limitations, largely linked with the retrospective, observational design, such as the possibility of residual treatment-by-indication bias, and the overall low rate of VTE recurrence.

Nonetheless, Professor Beverley Hunt, a Haematology Consultant at Guy’s and St. Thomas’ Hospitals NHS Foundation Trust, told the limbic that “although this study is flawed because it is retrospective, it provides important information on the efficacy and safety of DOACs in those with CVST.

“It shows that in a large population with CVST that DOACs (mainly apixaban) had similar rates of recurrent VTE as warfarin but lower rates of major bleeding. This study is reassuring for practice in the UK where DOACs are increasingly being used in the management of CVST.”

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